MEDICARE: EAST GREENWICH SPINE & SPORT, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician		RI

General Provider Information

NPI Number	:	1588689129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST GREENWICH SPINE & SPORT, INC.

Provider Business Mailing Address
First Line	:	1351 S COUNTY TRL
Second Line	:	BLG 1, SUITE100
City	:	EAST GREENWICH
State	:	RI
Zip	:	02818-5079
Country	:	US
Telephone Number	:	401-886-5907
Fax Number	:	401-885-6071

Provider Business Practice Location Address
First Line	:	1351 S COUNTY TRL
Second Line	:	BLG 1, SUITE 100
City	:	EAST GREENWICH
State	:	RI
Zip	:	02818-5079
Country	:	US
Telephone Number	:	401-886-5907
Fax Number	:	401-885-6071

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	MATTHEW JOSEPH SMITH
Credential	:	MD
Telephone Number	:	401-886-5907

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	04/01/2016

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